Government and nongovernmental organizations have consistently played a key role in addressing maternal mortality. While these initiatives are well documented, the role of faith-based organizations (FBOs) in maternal and newborn health is less well understood.

In November, the Wilson Center’s Advancing Policy Dialogue to Improve Maternal Health series will bring diverse institutions together such as the Pakistan Initiative for Mothers and Newborns (PAIMAN) and Pathfinder International to discuss country experiences and evaluate opportunities for overcoming challenges.

According to the World Health Organization, FBOs own up to 70 percent of the health infrastructure in sub-Saharan African countries and often work in remote regions where government and NGO services are limited. FBO’s are critical to improving maternal health as they fill gaps in the health system – particularly in low-resource settings – and approaching culturally sensitive barriers that often prevent mothers from seeking health care.

The level of trust communities place on their religious leaders explains one of the main reasons why FBOs are attaining success. A study conducted by Pew Charitable Trust found that a vast majority of people in sub-Saharan Africa identify themselves as adherents of Christianity or Islam, and approximately 75 percent trust their religious leaders.

As partnerships with FBO’s increase, it is imperative that organizations share their lessons learned and identify capacity and knowledge gaps in order to improve effectiveness.

Pakistan Initiative for Mothers and Newborns

The Pakistan Initiative for Mothers and Newborns (PAIMAN), which started out as a six-year project funded by USAID and led by JSI Research and Training Institute, is a strong example of a program incorporating faith to improve maternal mortality rates. The project aims to ensure that women have access to skilled birth attendants during and immediately after giving birth. Additionally, the project focused on increasing the quality of care both in the public and health sectors. PAIMAN was able to achieve substantial success by utilizing various communication interventions such as mass media, community media, and advocacy efforts. One of the most successful initiatives PAIMAN organized was reaching out to 1,000 religious scholars, known as ulamas, to deliver frequent messages on maternal and newborn health care. Since its initiation, this project has “saved more than 30,000 newborn lives resulting in a 23 percent decrease in neonatal mortality,” according to their numbers.

Pathfinder International

Pathfinder International is another great example of an organization that has understood the value of FBOs and worked in collaboration with them to achieve results for maternal health. Pathfinder has worked in numerous countries including Nigeria, Ghana, Ethiopia, Egypt, Uganda, Kenya, and Bangladesh to educate religious leaders and communities on communication strategies for improving maternal health behaviors.

In Ethiopia, Pathfinder organized over 250 religious leaders representing the Orthodox Christian, Catholic, Protestant, Seventh Day Adventist, Mekaneyesus Christian, and Muslim faiths to educate them about maternal mortality. At the conclusion of the seminar, the religious leaders agreed to condemn a host of harmful traditional practices, including female genital cutting, marriage by abduction, early marriage, rape, and unsafe abortion and agreed that they are not required by the Bible or Korean. Religious leaders in Egypt also came to similar conclusions after participating in these types of seminars.

Despite the prevalence of success stories among FBOs to improve maternal mortality, challenges do exist. For instance, although religious leaders are highly respected by their communities, their teachings become useless, as pointed out by a USAID-sponsored Extending Service Delivery Project report, unless they are also properly trained and equipped with the latest service delivery systems and scientific information.

The report also describes the importance of cooperation and support from the government and decision-making representatives. If the private, public, and government sectors are fragmented and no formal recognition exists to acknowledge the work of religious leaders for improving maternal mortality, then success may be significantly hampered.

To learn more about the role of faith-based organizations in women’s health, be sure to check out the Global Health Initiative event on FBOs coming in November, with representatives from PAIMAN, Pathfinder International, and others.

“Mainstreaming Environment and Climate Change: Health,” a joint publication from the International Institute for Environment and Development and Irish Aid, is part of a series that aims to show the links between the environment, climate change, and key development sectors, while suggesting key solutions to move into national policies. This health-focused briefing asserts that “nearly one quarter of the global disease burden can be attributed to the environment.” While anyone is prone to the negative effects of climate change, the poor are especially vulnerable because they often live in some of the most precarious environmental conditions. Consequently, the briefing argues that “improving environmental health – raising its profile at national, state and local levels, and integrating environmental health issues into development plans and activities – is critical if we are to reduce poverty and meet the Millennium Development Goals.”

In An Assessment of the Benefits of Integrating Family Planning and Environmental Management Activities in the Visayas Region of the Philippines, a study from the University of Rhode Island’s Coastal Resources Center, authors Richard B. Pollnac and Kira Dacanay argue that benefits can be reaped from integrated population, health and environment (PHE) development, but only under certain conditions. Factors influencing the level of benefits include “levels of participation in integrated projects [both by individuals and communities], and how NGOs implement these projects.” Thus, it is important to “tailor strategies based on place-based context and personal characteristics of different participants,” write Pollnac and Dacanay. In the Philippines, the authors suggest that one of the actions future PHE initiatives should take is to “stimulate more project participation, with special efforts in larger, less dense communities and tailor strategies better to different targeted populations within the community.”

Although obstetric fistula may not be as widely recognized as other maternal health issues, the Fistula Foundation estimates that over two million women and girls in developing countries suffer from this condition today. The World Health Organization has labeled it as “the single most dramatic aftermath of neglected childbirth.”

Obstetric fistula is a devastating condition often resulting from obstructed labor that can cause infections, incontinence, and even paralysis. The condition largely afflicts poor, rural, and illiterate women in developing countries who lack resources and access to emergency care and surgery, and sufferers often face an additional burden of social stigma.

Economic Development and Social Standing

Poor infrastructure and poverty significantly increases the occurrence rate of obstetric fistula. Lewis Wall, in an article for The Lancet, writes that “poverty is the breeding-ground where obstetric fistulas thrive.” Wall cites early marriage, low social status of women, malnutrition, inadequately developed social and economic infrastructures, and lack of access to emergency obstetric services as being major contributors of fistulas in developing countries.

Additionally, “postponing the age of marriage and delaying childbirth can significantly reduce the risk of subjecting young women to the arduous labor that induces fistulas,” wrote Sonny Inbaraj of Inter Press Service News Agency (IPS) in an article about how fistula makes social outcasts of child brides.

In most developing societies where child marriage is common, the social standing of women is defined largely in terms of marriage and childbearing. Child marriages are typically arranged without the knowledge or consent of the girls involved. The norms emphasize a girl’s domestic roles and de-emphasize investments such as education.

Stigmatization of Fistula

There is an undeniable link between fistula and social stigmatization. Rather than receiving assistance from their families and communities, women are often ostracized and in many instances exiled from their communities. This is especially true in developing countries where “the role of women is merely limited to providing sexual satisfaction for their husbands, [and] producing children,” said Dr. Catherine Hamlin, founder of the Addis Ababa Fistula Hospital, in an interview with IPS.

Thus far the fight to end fistula has attracted various government agencies and organizations including USAID, UNFPA, EngenderHealth, Maternal Health Task Force, and the Human Rights Watch. Outstanding individuals have also played a key role in fistula prevention efforts, like Drs. Reginald and Catherine Hamlin, Australian gynecologists who came to Addis Ababa in 1959 for temporary medical work, but after hearing heart-breaking stories from fistula patients, they decided to move to Ethiopia permanently and open the Addis Ababa Fistula Hospital. As the only hospital dedicated exclusively to women with obstetric fistula, the hospital provides care free of change, and has done so since 1974.

Although fistula has gotten some support and attention, the need to scale-up the prevention initiatives has never been greater. As a result of the “poverty and the stigma associated with their condition, most women living with fistulas remain invisible to policy makers both in their own countries and abroad,” wrote Inbaraj on IPS.

“Preventing fistula and restoring women’s health and dignity requires more than good policies on paper,” said Odhiambo at Human Rights Watch. Seriously tackling the issue will require much more than traditional medical and public health interventions – prevention efforts must also take into account underlying social issues, food and economic security.

Sources: The Addis Ababa Fistula Hospital, Campaign to End Fistula, The Center for Global Development, The Fistula Foundation, Human Rights Watch, The Lancet, World Health Organization.

When Aaron Wolf, professor in the Department of Geoscience at Oregon State University, and his colleagues first looked at the dynamics behind water conflict in their Basins at Risk study, they found that a lot of the issues they’d assumed would lead to conflict, like scarcity or economic growth, didn’t necessarily. Instead they found that “there is a relationship between change in a [water] basin and the institutional capacity to absorb that change,” said Wolf in this interview with ECSP. “The change can be hydrologic: you’ve got floods, droughts, agricultural production growing…or institutions also change: countries kind of disintegrate, or there are new nations along basins.”

However, these changes happen independently. “Whether there is going to be conflict or not depends in a large part to what kind of institutions there are to help mitigate for the impacts of that change,” explained Wolf.

“If you have a drought or economic boom within a basin and you have two friendly countries with a long history of treaties and working together, the likelihood of that spiraling into conflict is fairly low. On the other hand, the same droughts or same economic growth between two countries that don’t have treaties, or there is hostility or concern about the motives of the other, that then could lead to settings that are more conflictive.”

Wolf stressed the importance of understanding hydrologic variability in relation to existing treaties around the world. After carefully examining hundreds of treaties, he and his colleagues created a way of measuring their variability to try to find potential hotspots.

“We know how variable basins are around the world; we know how well treaties can deal with variability. You put them together and you have some areas of concern: You may want to look a little closely to see what is happening as people try to mitigate these impacts,” said Wolf.

“We know that one of the overwhelming impacts of climate change is that the world is going to get more variable: Highs are going to be higher, and lows are going to be lower,” Wolf said.

Wolf used the Himalayan basins to illustrate the importance of overseeing the potential effects of climate change and institutional capacity. “There are a billion and half people who rely on the waters that originate in the Himalayas,” he pointed out. Because of climate change, the Himalayas may experience tremendous flooding, and conversely, extreme drought.

Unfortunately, Wolf said, “the Himalayan basins…do not have any treaty coverage to deal with that variability.” Without treaties, it is difficult for countries to cooperate and setup a framework for mitigating the variability that might arise.

“Does Family Planning Bring Down Fertility” in Science’s special July issue on population, author Jocelyn Kaiser engages various experts to explore whether family planning programs actually help to reduce high fertility. Social demographer Amy Tsui of Johns Hopkins University argues that surveys indicating “unmet need” in family planning “don’t tell us anything about causation.” On the other hand, Martha Campbell, a lecturer at the University of California, stressed that in countries such as Niger where the population could soar from 16 million today to 58 million by 2050, “You can’t expand [schools] fast enough.” Thus, focusing on family planning is indispensable and “the benefits [will] far outweigh the costs.”

In “Population Policy in Transition in the Developing World,” also published in the population issue of Science, authors John Bongaarts and Steven Sinding explain why there has been renewed interest on family planning in developing countries. Since rapid population growth in the poorest countries is hampering development, “economists, once notably skeptical, increasingly acknowledge that fertility decline has beneficial economic effects for nations and families,” they write. Moving forward, Bongaarts and Sinding suggest family planning needs to be at the forefront of population and development discussions. Not only is family planning “cost effective,” they write, but it is responsible for “relieving population pressures, stimulating economic development, improving health, and enhancing human freedom.”

See the full line-up of articles from Science’s population edition here.

“Although there have been improvements in the recent past, the status of maternal health care has not met the required international standards,” said Professor at the University of Nairobi Geoffrey Mumia Osaaji during a live video-conference from Nairobi on July 12.

As part of the 2011 Maternal Health Dialogue Series the Woodrow Wilson Center’s Global Health Initiative is partnering with the African Population and Health Research Center to convene a series of technical meetings on improving maternal health in Kenya. The 20 Kenyan experts attending the workshop in Nairobi also shared their strategies and action points with a live audience in Washington, DC during a video conference discussion. [Video Below]

Osaaji was joined by panelists Lawrence Ikamari, director of Population Studies and Research Institute (PSRI), and Catherine Kyobutungi, director of Health Systems and Challenges at the African Population and Research Center to discuss new maternal health research in Kenya. Panelists also shared recommendations for moving the maternal health agenda forward that came out of discussions during the two-day, in-country workshop with Kenyan policymakers, community health workers, program managers, media, and donors. Following the panelists’ presentations, Dr. Nahed Mattta, senior maternal and newborn health advisor at U.S. Agency for International Development (USAID) and John Townsend, vice-president of reproductive health program for Population Council provided reflecting remarks from the Woodrow Wilson Center during the live webcast.

Maternal Health Challenges in Rural Kenya

“Maternal mortality in rural Kenya is still very high,” said Ikamari. “Rural women in Kenya need to have increased access to maternal health services.” Ikamari discussed a number of factors that contribute to high rates of maternal mortality in rural Kenya, including lack of access to quality care and skilled birth attendants, the high burden of HIV/AIDS, and an unmet need for family planning.

Though nearly 90 percent of women in rural Kenya seek antenatal care, according to the UNFPA, many wait until the second or third trimester, limiting the benefits. Additionally, a majority of women in rural Kenya give birth outside of health facilities, oftentimes without the care of a skilled birth attendant, said Ikamari. In a recent survey, many rural women indicated that transportation to often distant health facilities prevented them from seeking adequate maternal health care, he added.

Additionally, “the burden of HIV is really felt in rural Kenya,” said Ikamari. Survey results show that HIV/AIDS prevalence is about seven percent in rural Kenya and because the majority of the Kenyan population lives in rural areas, this adds yet another layer of complications.

“Family planning saves lives,” said Ikamari, stressing the importance of contraception on maternal health outcomes. Only 35 to 40 percent of currently married Kenyan women use family planning, according to the last demographic and health surveys, and unmet need remains particularly high in rural areas. Promoting institutional delivery systems, improving antenatal and postnatal care, and finding other ways to increase access to family planning can help to improve maternal health outcomes and reduce preventable deaths in rural Kenya, concluded Ikamari. Comparison of Urban and Rural Areas

“The interventions to address maternal health are well known: family planning, increased access to safe abortion services, skilled health workers, health facilities that are accessible, as well as referral systems that work,” said Kyobutungi. “Yet urban averages [of maternal mortality] are becoming either close or worse than rural averages.”

“As much as we appreciate the rural-urban divide that exists for most health indicators, the urban-urban divide (the fact that there are huge intra-urban differences) needs attention”

“Teenage pregnancy is a failure of family planning,” said Kyobutungi. Studies indicate that there are three times more teenagers that are pregnant among the urban poor, compared to the urban rich.

As in rural Kenya, access to quality health facilities and care is also limited in cities. “Health facilities are few and far between and the referral systems are weak,” said Kyobutungi, and “when you remove Nairobi from the numerator, the number of skilled physicians per population is in the decimals.”

Moving forward, there is a need to promote effective integration and improvement of health worker training and monitoring but also development of performance-based incentives to ensure successful programs are properly funded. “It’s not all gloom and doom in urban areas,” concluded Kyobutungi.

Innovative Ideas for Better Results

“By year 2025 there will be 25 percent more people [in Kenya],” said Townsend. “What that means is, when we are planning…we have to think about the scale of solutions that we are proposing in 2025 and 2050.” Therefore, it is essential to acquire new models of data and evidence to better predict future population growth and maternal needs, he suggested.

In addition to expanding services to meet the needs of a growing population, the panelists in Washington emphasized the need to support integration at all levels. Trends are moving in the right direction: Within the Obama administration’s Global Health Initiative, “there is a strong push and recommendation for integration among the health sectors,” said Matta.

But integration is not a magic bullet to improve maternal health, warned the panelists. “Integration is a terrific issue, but when the health sectors are weak, putting more burden on a local community health worker does not usually make sense; we have to think about smart integration,” said Townsend.

Focusing on Kenya’s health sector from all aspects, both at the private and public level, and improving family planning, institutional delivery care, as well as antennal care will help Kenya overcome its maternal health barriers. Additionally, thinking of ways to utilize new models of data and integrating the various sectors will yield substantial benefits, concluded Matta and Townsend.

Following the technical meeting, a public dialogue was held on July 13 in Nairobi to share the recommendations and knowledge gaps identified with members of Kenya’s Parliament, including Hon. Sofia Abdi, parliamentary health committee member; Hon. Ekwee Ethuro, chair of the parliamentary network for population and development; and Hon. Jackson Kiptanui. They joined a group of more than 50 maternal health experts, program managers, members of the media, and donors – such as the UK Department for International Development (DFID) – to identify real solutions and action points for improving maternal health in Kenya.

The formal report from the in-country technical meeting will be available in the near future.

See also the Maternal Health Task Force’s coverage of the event, here and here.

“The issues of population, health, and environment are pretty foreign to a lot of people,” said Alecia Fields, a recent University of Kentucky graduate who participated in a Sierra Club Global Population and Environment Study Tour of Ethiopia last summer as a student fellow.

“I learned about the program, how to be an effective advocate, and I took those tools back to my university on campus and shared it with young people,” said Fields in this interview with ECSP.

Fields came from a women’s health background but found the connections between population, health, and environment (PHE) compelling enough that she wanted to become an advocate on campus. “At first, people don’t think they have a connection to the issue, but once you start talking with people, they really start to see how they are central to a larger issue,” said Fields.

“It is challenging in the United States to see some of the population and environmental issues…but when you go to a developing country, you see the effects right in front of you,” explained Fields. The Sierra Club’s Global Population and Environment Study Tours bring a select group of student advocates abroad to see PHE projects in the field with the aim of creating pro-active messengers of the importance of integrated development in the United States.

Fields visited various sites and organizations in Ethiopia including the Gauraghe People’s Self-help Development Organization (GPSDO), located in the southwest region. “People in Ethiopia have had tremendous success in connecting population, health, and environment within communities and starting integrated programs that work towards development,” said Fields.

Going to Ethiopia provided Fields with concrete examples of the importance of PHE and allowed her to share her experience with young people through meaningful illustrations and moving stories.

“A lot of it deals with figuring out where people are in their attachment to the subject…and try to figure out how that program can connect to them,” she said.